1972893352 NPI number — SPH3 ENTERPRISE, LLC

Table of content: (NPI 1972893352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972893352 NPI number — SPH3 ENTERPRISE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPH3 ENTERPRISE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BUCKLAND HILLS DENTAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972893352
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
553 PORTLAND-COBALT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06480
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-342-4141
Provider Business Mailing Address Fax Number:
860-342-1284

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
194 BUCKLAND HILLS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06042-8705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-342-4141
Provider Business Practice Location Address Fax Number:
860-342-1284
Provider Enumeration Date:
04/19/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HO
Authorized Official First Name:
TAE
Authorized Official Middle Name:
CHUL
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
860-342-4141

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  009846 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 009920 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 009785 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0106X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)